Displaced intra-articular calcaneus fractures (DIACFs) are difficult injuries to treat and are often encountered by orthopedic surgeons. For DIACFs treated nonoperatively or with open reduction ...internal fixation (ORIF), a common complication is painful subtalar arthritis and the need for a secondary subtalar fusion, which prolongs the overall recovery time. One treatment option to address this sequela involves ORIF with subtalar fusion as the primary treatment. We describe a reproducible, minimally invasive surgical technique for primary ORIF with subtalar fusion when the calcaneal tuberosity is amendable to cannulated screw fixation to treat these complex calcaneal fractures. Our technique offers advantages compared to other techniques in that it avoids screw traffic, allows easy bony compression of the subtalar joint, and minimizes soft tissue damage via percutaneous screw fixation. Fourteen fractured calcanei in 12 patients underwent our technique and all achieved bony union with a median time to fusion of 107.5 days (range, 54-530 days). Eight patients returned to work with the remaining 4 patients having an unknown work status at last follow-up, although 2 of these 4 patients resumed normal activities. Only 1 patient experienced a complication, which was an infection after achieving bony union, and was treated with successful hardware removal and our infection protocol. Overall, we conclude our surgical technique offers a successful option in the treatment of DIACFs when the calcaneal tuberosity is amendable to cannulated screw fixation.
Opioid-related adverse drug events continue to occur. This study aimed to characterize the patient population receiving naloxone to inform future intervention efforts.
We describe a case series of ...patients who received naloxone in the hospital during a 16-week time frame in 2016. Data were collected on other administered medications, reason for admission to the hospital, pre-existing diagnoses, comorbidities, and demographics.
Twelve hospitals within a large healthcare system.
46,952 patients were admitted during the study period. 31.01 percent (n = 14,558) of patients received opioids, of which 158 received naloxone.
Administration of naloxone. Main outcome of interest: Sedation assessment via Pasero Opioid-Induced Sedation Scale (POSS), administration of sedating medications.
POSS score was documented prior to opioid administration in 93 (58.9 percent) patients. Less than half of patients had a POSS documented prior to naloxone administration with 36.8 percent documented 4 hours prior. 58.2 percent of patients received multimodal pain therapy with other nonopioid medications. Most patients received more than one sedating medication concurrently (n = 142, 89.9 percent).
Our findings highlight areas for intervention to prevent opioid oversedation. Investing in electronic clinical decision support mechanisms, such as sedation assessment, could detect patients at risk for oversedation and ultimately prevent the need for naloxone. Coordinated order sets for pain management can reduce the percentage of patients receiving multiple sedating medications and promote the use of multimodal pain management in efforts to reduce opioid reliance while optimizing pain control.
Category:
Hindfoot; Trauma
Introduction/Purpose:
The initial management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem. The results of open reduction internal ...fixation (ORIF) have been disappointing. Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using screws alone through a sinus tarsi approach.
Methods:
A retrospective study of all patients from 2013-2019 who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was utilized in all cases consisting of only screws, no plates were utilized. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data was collected. Worker's compensation (WC) claims were noted and analyzed separately. Plain radiographs were assessed preoperatively and post-operatively and Sander's classification was used to characterize injuries. Patient reported outcomes (PROs), complications, and need for revision surgeries was also noted and analyzed at final follow-up.
Results:
In total, forty-eight DIACFs underwent PSTA with a median follow-up of 194 days. Median time to weight-bearing was 60 days post-operatively. Three fractures were documented as Sanders II, 22 as Sanders III, and 23 as Sanders IV. Seventy-five percent of the WC group returned to work compared to just 58.3% in the non-WC group (p=0.0003). Patients in the WC group were more likely to have had an abnormal pre-operative Bohler's angle (p=0.047) but the two groups did not differ significantly in postoperative Gissane or Bohler angles. Nearly 85% (N=41) achieved >=2 zones of fusion on radiographs by final follow up and 95.8% (N=46) had at least one. Four patients had a complication and 3 required a return to the operative room.
Conclusion:
Utilizing Screws only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach shows promising results with high rates of return to work and fusion, even in the workers' compensation population.
Alcohol abuse and nonalcoholic fatty liver disease (NAFLD) are common causes of liver disease. Diabetes mellitus (DM) is a common comorbidity among NAFLD patients. We performed this study with the ...specific aim to examine the impact of DM on progression of alcoholic liver disease (ALD) liver and NAFLD.
Medical charts of 480 patients with ALD or NAFLD (2004-2011) managed at a tertiary center were retrospectively reviewed. NAFLD was diagnosed based on exclusion of other causes of liver disease and alcohol use of <10 g/d. ALD was diagnosed based on alcohol use of >40 g/d in women or >60 g/d in men for >5 years.
Of 480 patients (307 NAFLD), 200 diabetics differed from nondiabetics for: age (52±11 vs. 49±11 years; p=0.004); male gender (48% vs. 57%; p=0.03); metabolic syndrome (49% vs. 30%; p=0.0002); NAFLD (80% vs. 56%; p<0.0001); cirrhosis (70% vs. 59%; p=0.005); and hepatocellular carcinoma (HCC; 8% vs. 3%; p=0.009). Over a 3 year median follow-up period, diabetics relative to nondiabetics had a higher probability to develop cirrhosis (60% vs. 41%; p=0.022) and HCC (27% vs. 10%; p=0.045). There was a trend for increased development of hepatic encephalopathy in diabetics compared to nondiabetics (55% vs. 39%; p=0.053), and there was no difference between the two groups in survival or other liver disease complications.
DM increased risk for cirrhosis and HCC among patients with ALD and NAFLD. Prospective studies with longer follow-up periods are needed to examine the impact of DM on survival and the role of aggressive HCC screening in diabetic cirrhotics.
Introduction
This study reports on the impact of a clinical decision support tool embedded in the electronic medical record and characterizes the demographics, prescribing patterns, and risk factors ...associated with opioid and benzodiazepine misuse in the older adult population.
Significance
This study reports on prescribing patterns for patients ≥65 years-old who presented to Emergency Departments (ED) or Urgent Care (UC) facilities across a large healthcare system following a fall (n = 34,334 encounters; n = 25,469 patients). This system implemented a clinical decision support intervention which provides an alert when the patient has an evidence-based risk factor for prescription drug misuse; prescribers can continue, amend or cancel the prescription.
Results
Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid or benzodiazepine prescription. Women and younger patients (65-74) had a higher likelihood of receiving a prescription (P < .0001). 11% had ≥1 risk factor. Women were more likely to receive an early refill (P = .0002) and younger (65-74) men were more likely to have a past positive toxicology (P < .0001). A prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an alert. In 58 cases, the alert resulted in a prescription modification, and in 80 the prescription was canceled.
Conclusions
Documented risk for opioid misuse in the elderly was 10% among patients presenting to the ED/UC after a fall. The dangers associated with opioid/benzodiazepine use increase with age as does fall risk. Awareness of risk factors is an important first step; more work is needed to address potentially hazardous prescriptions in this population.
Objective Most patients with erythropoietic protoporphyria have deficient ferrochelatase (FECH) activity due to changes in FECH DNA. We evaluated seven patients with erythropoietic protoporphyria ...phenotype in whom abnormalities of FECH DNA were not found by conventional analysis. The major focus was mitoferrin-1 (MFRN1), the mitochondrial transporter of Fe used for heme formation by FECH and for 2Fe2S cluster synthesis, which is critical to FECH activity/stability. Materials and Methods Four patients had a deletion in ALAS2 that causes enzyme gain-of-function, resulting in increased formation of protoporphyrin; one had a heterozygous major deletion in FECH DNA. All had an abnormal transcript of MFRN1 in messenger RNA extracted from blood leukocytes and/or liver tissue. The abnormal transcript contained an insert of intron 2 that had a stop codon. The consequences of abnormal MFRN1 expression were examined using zebrafish and yeast MFRN -deficient strains and cultured lymphoblasts from the patients. Results Abnormal human MFRN1 complementary DNA showed loss-of-function in zebrafish and yeast mutants, whereas normal human MFRN1 complementary DNA rescued both. Using cultured lymphoblasts, quantitative reverse transcription polymerase chain reaction showed increased formation of abnormal transcript that was accompanied by decreased formation of normal transcript and reduced FECH activity in patients compared to normal lines. A positive correlation coefficient (0.75) was found between FECH activity and normal MFRN1 messenger RNA in lymphoblasts. However, no obvious cause for increased formation of abnormal transcript was identified in MFRN1 exons and splice junctions. Conclusions Abnormal MFRN1 expression can contribute to erythropoietic protoporphyria phenotype in some patients, probably by causing a reduction in FECH activity.
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